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Medical Services and Department of Medicine High Value Care: Optimal Approach to Imaging for Low Back Pain Ilana Richman MD, Primary Care and Outcomes.

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Presentation on theme: "Medical Services and Department of Medicine High Value Care: Optimal Approach to Imaging for Low Back Pain Ilana Richman MD, Primary Care and Outcomes."— Presentation transcript:

1 Medical Services and Department of Medicine High Value Care: Optimal Approach to Imaging for Low Back Pain Ilana Richman MD, Primary Care and Outcomes Research Fellow Anne Smeraglio MD, Resident in Internal Medicine

2 Medical Services and Department of Medicine Objectives Differentiate patients with back pain due to a specific etiology versus those with nonspecific back pain Identify patients who should and should not be referred for imaging for low back pain Discuss the rationale for deferring imaging in patients with low-risk back pain

3 Medical Services and Department of Medicine Case 1 45 year old man with a past medical history of hypertension comes to clinic reporting three weeks of nagging low back pain. Pain is dull, moderate in intensity, does not radiate, somewhat relieved by over the counter analgesics, made worse with long periods of sitting or standing, better with lying down

4 Medical Services and Department of Medicine Case 1 What is your differential diagnosis? What other questions would you ask? What would you focus on in your physical exam?

5 Medical Services and Department of Medicine Case 1 No weight loss, personal history of cancer, history of AAA, neurological symptoms, fevers, chills, or escalating pain Neurologic exam is completely normal

6 Medical Services and Department of Medicine Case 1 Does this patient require imaging of the low back? Why or why not?

7 Medical Services and Department of Medicine Case 2 A 49 year old woman with comes to clinic with a complaint of back pain. She has a history of stage 3A ER/PR+ breast cancer that was treated two years ago with chemotherapy and surgery. She is currently taking tamoxifen. Her pain started last week after bending over for several hours gardening. It is dull, centered over the lumbar area, alleviated with ibuprofen, somewhat better with rest. No fevers or chills. No new neurologic symptoms.

8 Medical Services and Department of Medicine Case 2 What additional history would be helpful? What would you look for on exam? Would you image this patient? If so, with which modality?

9 Medical Services and Department of Medicine

10 You will encounter low back pain very frequently in your continuity clinic

11 Medical Services and Department of Medicine Questions We Will Answer In this Hour Why do we image patients with low back pain? What are the common causes of low back pain? When is imaging appropriate and can we use the history and exam to guide this decision? When imaging is appropriate, which modalities should we use? Which patients do not need imaging immediately and what happens if we image them anyway? How are we doing?

12 Medical Services and Department of Medicine Questions We Will Answer In this Hour Why do we image patients with low back pain? What are the common causes of low back pain? When is imaging appropriate and can we use the history and exam to guide this decision? When imaging is appropriate, which modalities should we use? Which patients do not need imaging immediately and what happens if we image them anyway? How are we doing?

13 Medical Services and Department of Medicine Why Do Patients Receive Imaging for Low Back Pain? Patient preference: Worried about serious pathology Want to understand the reason for a new symptom  Want to feel validated or cared for Provider preference:  Concern for serious underlying pathology  Worried about “missing something”  Because imaging exists  Want to please patients

14 Medical Services and Department of Medicine Imaging: Supply Sensitive Care? Baras J D, and Baker L C Health Aff 2009;28:w1133-w1140

15 Medical Services and Department of Medicine Questions We Will Answer In this Hour Why do we image patients with low back pain? What are the common causes of low back pain? When is imaging appropriate and can we use the history and exam to guide this decision? When imaging is appropriate, which modalities should we use? Which patients do not need imaging immediately and what happens if we image them anyway? How are we doing?

16 Medical Services and Department of Medicine What proportion of back pain is musculoskeletal in etiology and will typically resolve with conservative measures?  25%  60%  85%  98%

17 Medical Services and Department of Medicine What proportion of back pain is musculoskeletal in etiology and will typically resolve with conservative measures?  25%  60%  85%  98%

18 Medical Services and Department of Medicine Common Causes of Acute Back Pain Presumed musculoskeletal (85%) Spinal stenosis (3%) Disc bulge/herniation (4%) Compression fracture/other fracture (4%) Infection (0.01%) Malignancy (0.7%) Inflammatory arthritis (0.3-5%) Visceral disease (AAA, pancreatitis, etc.) Chou et al. Ann Intern Med. 2007;147(7):478-491

19 Medical Services and Department of Medicine Questions We Will Answer In this Hour Why do we image patients with low back pain? What are the common causes of low back pain? When is imaging appropriate and can we use the history and exam to guide this decision? When imaging is appropriate, which modalities should we use? Which patients do not need imaging immediately and what happens if we image them anyway? How are we doing?

20 Medical Services and Department of Medicine When is Imaging Appropriate? “Red Flag Symptoms”  Symptoms suggestive of underlying specific pathology including malignancy, fracture, infection etc.  No universally agreed upon list Neurologic symptoms  New bowel or bladder dysfunction  Sensory disturbances  Weakness  Radicular symptoms  Pseudoclaudication Neurologic signs: weakness, numbness, abnormal reflexes, abnormal sphincter tone etc.

21 Medical Services and Department of Medicine ACP Guidelines Red Flag Symptoms Age >70 History of malignancy History of AAA Fever or recent infection Weakness, bowel or bladder disturbance Unremitting (>6 weeks) or worsening pain Trauma Weight loss Immunosuppression Prior surgery Prolonged corticosteroid use or known osteoporosis

22 Medical Services and Department of Medicine Are Red Flag Symptoms Helpful? Deyo et al., JAMA. 1992;268(6):760-765

23 Medical Services and Department of Medicine Are Red Flag Symptoms Helpful? Spinal Fracture Downie A et al. BMJ 2013;347:bmj.f7095

24 Medical Services and Department of Medicine Are Red Flag Symptoms Helpful? Malignancy Downie A et al. BMJ 2013;347:bmj.f7095

25 Medical Services and Department of Medicine Bottom Line Imaging is appropriate when you suspect a specific pathology and the patient might benefit from intervention Two caveats:  Not all pathologies are emergencies and not all require immediate intervention (or intervention at all)  The history and physical are admittedly imperfect but better than nothing for informing your decision-making

26 Medical Services and Department of Medicine Questions We Will Answer In this Hour Why do we image patients with low back pain? What are the common causes of low back pain? When is imaging appropriate and can we use the history and exam to guide this decision? When imaging is appropriate, which modalities should we use? Which patients do not need imaging immediately and what happens if we image them anyway? How are we doing?

27 Medical Services and Department of Medicine Which Imaging Modalities are Appropriate? Clinical SituationImaging Urgency Imaging Modality New neurologic deficit including progressive motor weaknessImmediateMRI Cauda equina syndromeImmediateMRI Suspicion for spinal infectionImmediateMRI Major risk factors for cancer or high clinical suspicion for cancerImmediatePlain films + ESR/CRP Risk factors for compression fractureDeferredPlain films Suspicion for ankylosing spondylitisDeferredPlain films Signs and symptoms of radiculopathy and a candidate for invasive treatment DeferredMRI Signs and symptoms of spinal stenosis and a candidate for invasive treatment DeferredMRI Lower suspicion for malignancy but with some risk factorsDeferredPlain film + ESR/CRP No criteria for immediate imaging or pain resolved after 1 month No imaging Chou et al. Ann Intern Med. 2007;147(7):478-491

28 Medical Services and Department of Medicine Questions We Will Answer In this Hour Why do we image patients with low back pain? What are the common causes of low back pain? When is imaging appropriate and can we use the history and exam to guide this decision? When imaging is appropriate, which modalities should we use? Which patients do not need imaging immediately and what happens if we image them anyway? How are we doing?

29 Medical Services and Department of Medicine Who does not need imaging? Patients with “nonspecific” back pain:  Acute (<6 weeks)  No historical features that suggest a particular underlying condition  No radicular symptoms or pseudoclaudication  Normal neurologic exam

30 Medical Services and Department of Medicine Question When imaging patients with nonspecific back pain, how many will have evidence of a herniated disc? A. 10% B. 20% C. 50% D. 80%

31 Medical Services and Department of Medicine Answer When imaging patients with nonspecific back pain, how many will have evidence of a herniated disc? A. 10% B. 20% C. 50% D. 80%

32 Medical Services and Department of Medicine The problem with imaging is that you find things… Imaging Modality in Healthy Middle Aged Patients Herniated DiscBulging Disc Degenerative Disc Stenosis Plain radiographs -- 20%- CT20-27--0-3 MRI30 (9-76)50 (20-81)60 (46-91)1-21 Jarvik et al., Ann Intern Med. 2002;137(7):586-597

33 Medical Services and Department of Medicine And Then Do Things… Baras JD and Baker LC Health Aff 2009;28:w1133-w1140

34 Medical Services and Department of Medicine And More Things… Graves et al. HSR. 49:2 (April 2014)

35 Medical Services and Department of Medicine Will We Cause Harm by Deferring Imaging? Chou et al., The Lancet, Volume 373, Issue 9662, 2009, 463 - 472

36 Medical Services and Department of Medicine Questions We Will Answer In this Hour Why do we image patients with low back pain? What are the common causes of low back pain? When is imaging appropriate and can we use the history and exam to guide this decision? When imaging is appropriate, which modalities should we use? Which patients do not need imaging immediately and what happens if we image them anyway? How are we doing?

37 Medical Services and Department of Medicine How Are We Doing? Utilization of imaging Appropriateness of imaging Cost associated with imaging

38 Medical Services and Department of Medicine Utilization of Imaging Carey TS et al. N Engl J Med 1995;333:913-917.

39 Medical Services and Department of Medicine Trends in Imaging Utilization Deyo, JABFM, 2009 Jan-Feb;22(1):62-8.

40 Medical Services and Department of Medicine Costs Associated with Imaging Chou et al., Ann Intern Med. 2011;154(3):181-189

41 Medical Services and Department of Medicine Overall Costs for Back Pain are Increasing Martin et al., JAMA. 2008;299(6):656-664.

42 Medical Services and Department of Medicine Without an Obvious Return on Investment Martin et al., JAMA. 2008;299(6):656-664

43 Medical Services and Department of Medicine Is Imaging Use Appropriate? Emery et al., JAMA Intern Med. 2013;173(9):823-825

44 Medical Services and Department of Medicine Back to the Cases Case 1:  Would you image?  What would you say to the patient if he requested imaging?  What options for conservative management are there? Case 2:  Would you image?  What modality would you choose?

45 Medical Services and Department of Medicine Summary Nonspecific low back pain is common and usually self-limited Certain features of the history and exam are helpful for distinguishing back pain likely to be due to specific pathology Imaging is usually not indicated for patients with nonspecific back pain and not only is costly but can result in additional interventions


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